Facial wounds are the most cosmetically apparent of all wounds and therefore warrant careful evaluation and meticulous repair technique for the best possible outcome. Most facial and scalp lacerations can be closed by the emergency physician, but consult with specialists if the technical aspects of closure are complex or exceed the skill of the individual practitioner.
Three common principles guide repair of facial and scalp lacerations.1 First, cleanse, irrigate, and remove foreign material to minimize infection. Second, limit debridement of skin edges because the excellent blood supply enables tissues to recover that may initially appear nonviable. And third, consider regional nerve blocks or topical anesthesia if local anesthetic infiltration would distort anatomy or hinder wound edge alignment (see Chapter 36, “Local and Regional Anesthesia”).2
Use nonabsorbable monofilament suture for facial skin. Rapidly absorbable suture and tissue adhesives are alternatives in selected locations and in some patients (e.g., patients who are unlikely to return for suture removal or selected wounds in children) (Table 42-1).3,4 Use absorbable suture for mucosa and fascial layers. To minimize scarring, place percutaneous sutures on the face 1 to 2 mm from the wound edges, 2 mm apart, with everted edges. Place mucosal sutures 2 to 3 mm from the wound edges, 2 to 3 mm apart, and superficial including only the mucosa and not the underlying muscle or fascia. Magnification with surgical loupes may facilitate more accurate suture placement in facial wounds.
TABLE 42-1Indications for Tissue Adhesives on the Face
Ask about the possibility of domestic violence in patients with facial injuries, and notify appropriate authorities if suspected (Table 42-2).5-8
TABLE 42-2Maxillofacial Injuries and Domestic Violence in the ED |Favorite Table|Download (.pdf) TABLE 42-2 Maxillofacial Injuries and Domestic Violence in the ED
Most victims of domestic violence have maxillofacial injuries.
Women are more commonly affected than men.
Fist is most common weapon.
Left side of face is most common site of injury (from right-hand-dominant assailants).
Nasal bone is commonly fractured.
Facial and scalp wounds are most often caused by a combination of sharp and blunt mechanisms. Lacerations caused by sharp objects likely have discrete edges, but may extend deeply and involve underlying structures, such as the muscles of facial expression, nerves, and arteries. Wounds caused by blunt forces burst the skin open, damage cells, and produce tissue edema, all of which slow the wound-healing process and increase risk for infection. Blunt forces are also more likely to cause diffuse underlying damage, such as fractures of the facial bones or skull.